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2.
Artigo em Inglês | MEDLINE | ID: mdl-33211087

RESUMO

Importance: Full-thickness tracheal lesions and tracheoesophageal fistulas are severe complications of invasive mechanical ventilation. The incidence of tracheal complications in ventilated patients with coronavirus disease 2019 (COVID-19) is unknown. Objective: To evaluate whether patients with COVID-19 have a higher incidence of full-thickness tracheal lesions and tracheoesophageal fistulas than matched controls and to investigate potential mechanisms. Design, Setting, and Participants: This is a retrospective cohort study in patients admitted to the intensive care unit in a tertiary referral hospital. Among 98 consecutive patients with COVID-19 with severe respiratory failure, 30 underwent prolonged (≥14 days) invasive mechanical ventilation and were included in the COVID-19 group. The control group included 45 patients without COVID-19. Patients with COVID-19 were selected from March 1 to May 31, 2020, while the control group was selected from March 1 to May 31, 2019. Exposures: Patients with COVID-19 had severe acute respiratory syndrome coronavirus 2 infection diagnosed by nasopharyngeal/oropharyngeal swabs and were treated according to local therapeutic procedures. Main Outcomes and Measures: The primary study outcome was the incidence of full-thickness tracheal lesions or tracheoesophageal fistulas in patients with prolonged invasive mechanical ventilation. Results: The mean (SD) age was 68.8 (9.0) years in the COVID-19 group and 68.5 (14.1) years in the control group (effect size, 0.3; 95% CI, -5.0 to 5.6). Eight (27%) and 15 (33%) women were enrolled in the COVID-19 group and the control group, respectively. Fourteen patients (47%) in the COVID-19 group had full-thickness tracheal lesions (n = 10, 33%) or tracheoesophageal fistulas (n = 4, 13%), while 1 patient (2.2%) in the control group had a full-thickness tracheal lesion (odds ratio, 38.4; 95% CI, 4.7 to 316.9). Clinical and radiological presentations of tracheal lesions were pneumomediastinum (n = 10, 71%), pneumothorax (n = 6, 43%), and/or subcutaneous emphysema (n = 13, 93%). Conclusions and Relevance: In this cohort study, almost half of patients with COVID-19 developed full-thickness tracheal lesions and/or tracheoesophageal fistulas after prolonged invasive mechanical ventilation. Attempts to prevent these lesions should be made and quickly recognized when they occur to avoid potentially life-threatening complications in ventilated patients with COVID-19.

3.
Artigo em Inglês | MEDLINE | ID: mdl-33036889

RESUMO

OBJECTIVES: Transcatheter aortic valve replacement (TAVR) has become an alternative treatment for patients with symptomatic aortic stenosis not eligible for surgical valve replacement due to a high periprocedural risk or comorbidities. However, there are several areas of debate concerning the pre-, intra- and post-procedural management. The standards and management for these topics may vary widely among different institutions and countries in Europe. DESIGN: Structured web-based, anonymized, voluntary survey. SETTING: Distribution of the survey via email among members of the European Association of Cardiothoracic Anaesthesiology working in European centers performing TAVR between September and December 2018. PARTICIPANTS: Physicians. MEASUREMENTS AND MAIN RESULTS: The survey consisted of 25 questions, including inquiries regarding number of TAVR procedures, technical aspects of TAVR, medical specialities present, preoperative evaluation of TAVR candidates, anesthesia regimen, as well as postoperative management. Seventy members participated in the survey. Reporting members mostly performed 151-to-300 TAVR procedures per year. In 90% of the responses, a cardiologist, cardiac surgeon, cardiothoracic anesthesiologist, and perfusionist always were available. Sixty-six percent of the members had a national curriculum for cardiothoracic anesthesia. Among 60% of responders, the decision for TAVR was made preoperatively by an interdisciplinary heart team with a cardiothoracic anesthesiologist, yet in 5 countries an anesthesiologist was not part of the decision-making. General anesthesia was employed in 40% of the responses, monitored anesthesia care in 44%, local anesthesia in 23%, and in 49% all techniques were offered to the patients. In cases of general anesthesia, endotracheal intubation almost always was performed (91%). It was stated that norepinephrine was the vasopressor of choice (63% of centers). Transesophageal echocardiography guiding, whether performed by an anesthesiologist or cardiologist, was used only ≤30%. Postprocedurally, patients were transferred to an intensive care unit by 51.43% of the respondents with a reported nurse-to-patient ratio of 1:2 or 1:3, to a post-anesthesia care unit by 27.14%, to a postoperative recovery room by 11.43%, and to a peripheral ward by 10%. CONCLUSION: The results indicated that requirements and quality indicators (eg, periprocedural anesthetic management, involvement of the anesthesiologist in the heart team, etc) for TAVR procedures as published within the European guideline are largely, yet still not fully implemented in daily routine. In addition, anesthetic TAVR management also is performed heterogeneously throughout Europe.

4.
Clin Infect Dis ; 2020 Sep 17.
Artigo em Inglês | MEDLINE | ID: mdl-32941593

RESUMO

Ten critically-ill patients with either bacteremia or ventilator-associated pneumonia caused by carbapenem-resistant A. baumannii, S. maltophilia or NDM-producing K. pneumoniae received cefiderocol. All strains had MIC ≤2 µg/mL. Thirty-day clinical success and survival rates were 70% and 90%, respectively. Two patients had a microbiological failure. Future prospective studies are warranted.

5.
Minerva Anestesiol ; 2020 Aug 04.
Artigo em Inglês | MEDLINE | ID: mdl-32755093

RESUMO

A large number of patients admitted to ICU display hemodynamic deterioration at some time during their stay. The management of acute hemodynamic derangement of any cause can be difficult and has to be accomplished quickly and correctly as delayed and inappropriate resuscitation treatments carry increased mortality. Cardiovascular insufficiency shows end-organ hypoperfusion-associated dysfunction, thus decreasing level of consciousness, falling urine output, ileus, new onset tachypnea and the presence of skin mottling are important clinical clues to cardiovascular deterioration and should be promptly looked for and if detected alert the bedside clinician that further assessment and potentially treatment is necessary. Although measures of serum lactate are useful to document the presence of tissue hypoperfusion, they are non-specific in defining its etiology. In a patient with acute hemodynamic instability, we propose a step-by-step approach as follows: 1) rapid initial ultrasound assessment of heart function: we recommend immediate transthoracic echocardiogram in any patient with acute hemodynamic alteration before starting specific treatments. 2) pathophysiological understanding of heart and circulation interaction: we recommend using a non-invasive approach to assess ventriculo-arterial coupling. 3) functional hemodynamic monitoring: we recommend using a functional hemodynamic monitoring (FHM) approach with passive leg raising manoeuvre (PLR) in all patients. 4) treatment: we recommend to treat the hemodynamic derangement based on the echocardiographic evaluation and pathophysiological understanding improved by assessing the interaction between the heart and the circulation. We named such approach BEAT, which stands for: Browse the heart, measure the Elastances, Assess volume status, and Treat. Combining bedside echocardiography, including the evaluation of the interaction between the heart and the circulation, with FHM offers the opportunity to personalise the hemodynamic management to the specific requirements.

6.
Cardiovasc Ultrasound ; 18(1): 25, 2020 Jul 06.
Artigo em Inglês | MEDLINE | ID: mdl-32631355

RESUMO

BACKGROUND: Pulmonary embolism (PE) is a life-threatening disease difficult to diagnose and manage in severe hemodynamic unstable patients. Transoesophageal echocardiography (TEE) is considered useful to improve diagnosis, but such approach has physical limitations for the interposition of the airways preventing the clear assessment of the left pulmonary artery. Endobronchial ultrasound (EBUS), a recently developed technique carried out using a modified bronchoscope having a small ultrasound convex probe at the tip allowing to perform ultrasonography examination of the mediastinum, can extensively visualize the pulmonary arteries on both sides. CASE PRESENTATION: We present the first use of EBUS to rapidly diagnose and subsequently treat a 64 years old woman with history of lateral amyotrophic sclerosis admitted to the intensive care unit (ICU) for severe dyspnoea and rapidly experiencing a cardiac arrest. CONCLUSIONS: Combined bedside EBUS and echocardiography allowed to rapidly diagnose the cause of cardiac arrest and avoid risks related to transferring the critical patient to the radiology department.

7.
J Cardiovasc Pharmacol ; 76(1): 4-22, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32639325

RESUMO

Levosimendan was first approved for clinical use in 2000, when authorization was granted by Swedish regulatory authorities for the hemodynamic stabilization of patients with acutely decompensated chronic heart failure (HF). In the ensuing 20 years, this distinctive inodilator, which enhances cardiac contractility through calcium sensitization and promotes vasodilatation through the opening of adenosine triphosphate-dependent potassium channels on vascular smooth muscle cells, has been approved in more than 60 jurisdictions, including most of the countries of the European Union and Latin America. Areas of clinical application have expanded considerably and now include cardiogenic shock, takotsubo cardiomyopathy, advanced HF, right ventricular failure, pulmonary hypertension, cardiac surgery, critical care, and emergency medicine. Levosimendan is currently in active clinical evaluation in the United States. Levosimendan in IV formulation is being used as a research tool in the exploration of a wide range of cardiac and noncardiac disease states. A levosimendan oral form is at present under evaluation in the management of amyotrophic lateral sclerosis. To mark the 20 years since the advent of levosimendan in clinical use, 51 experts from 23 European countries (Austria, Belgium, Croatia, Cyprus, Czech Republic, Estonia, Finland, France, Germany, Greece, Hungary, Italy, the Netherlands, Norway, Poland, Portugal, Russia, Slovenia, Spain, Sweden, Switzerland, the United Kingdom, and Ukraine) contributed to this essay, which evaluates one of the relatively few drugs to have been successfully introduced into the acute HF arena in recent times and charts a possible development trajectory for the next 20 years.

8.
Artigo em Inglês | MEDLINE | ID: mdl-32624431

RESUMO

Lung ultrasound (LU) has a multitude of features and capacities that make it a useful medical tool to assist physicians contending with the pandemic spread of novel coronavirus disease-2019 (COVID-19) caused by coronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Thus, an LU approach to patients with suspected COVID-19 is being implemented worldwide. In noncritical COVID-19 patients, 2 new LU signs have been described and proposed, the "waterfall" and the "light beam" signs. Both signs have been hypothesized to increase the diagnostic accuracy of LU for COVID-19 interstitial pneumonia. In critically ill patients, a distinct pattern of LU changes seems to follow the disease's progression, and this information can be used to guide decisions about when a patient needs to be ventilated, as occurs in other disease states similar to COVID-19. Furthermore, a new algorithm has been published, which enables the automatic detection of B-lines as well as quantification of the percentage of the pleural line associated with lung disease. In COVID-19 patients, a direct involvement of cardiac function has been demonstrated, and ventilator-induced diaphragm dysfunction might be present due to the prolonged mechanical ventilation often involved, as reported for similar diseases. For this reason, cardiac and diaphragm ultrasound evaluation are highly important. Last but not least, due to the thrombotic tendency of COVID-19 patients, particular attention also should be paid to vascular ultrasound. This review is primarily devoted to the study of LU in COVID-19 patients. The authors explain the significance of its "light and shadows," bearing in mind the context in which LU is being used-the emergency department and the intensive care setting. The use of cardiac, vascular, and diaphragm ultrasound is also discussed, as a comprehensive approach to patient care.

9.
J Cardiothorac Vasc Anesth ; 34(10): 2581-2585, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32665178

RESUMO

This article discusses the impact of the COVID-19 pandemic on the EACTA fellowship program. The authors present three points that in their view are important and give cause for concern because they could make it difficult or impossible to achieve the original goals of the fellowship program. Corresponding points are discussed and possible solutions are presented. An implementation in the fellowship curriculum is planned.


Assuntos
Anestesia em Procedimentos Cardíacos/tendências , Betacoronavirus , Infecções por Coronavirus/epidemiologia , Bolsas de Estudo/tendências , Pandemias , Pneumonia Viral/epidemiologia , Avaliação de Programas e Projetos de Saúde/tendências , Anestesia em Procedimentos Cardíacos/métodos , Anestesiologistas/educação , Anestesiologistas/tendências , Europa (Continente)/epidemiologia , Bolsas de Estudo/métodos , Humanos , Avaliação de Programas e Projetos de Saúde/métodos
10.
Artigo em Inglês | MEDLINE | ID: covidwho-258610

RESUMO

The novel coronavirus has caused a pandemic around the world. Management of patients with suspected or confirmed coronavirus infection who have to undergo thoracic surgery will be a challenge for the anesthesiologists. The thoracic subspecialty committee of European Association of Cardiothoracic Anaesthesiology (EACTA) has conducted a survey of opinion in order to create recommendations for the anesthetic approach to these challenging patients. It should be emphasized that both the management of the infected patient with COVID-19 and the self-protection of the anesthesia team constitute a complicated challenge. The text focuses therefore on both important topics.

11.
Artigo em Inglês | MEDLINE | ID: covidwho-46313

RESUMO

The novel coronavirus has caused a pandemic around the world. Management of patients with suspected or confirmed coronavirus infection who have to undergo thoracic surgery will be a challenge for the anesthesiologists. The thoracic subspecialty committee of European Association of Cardiothoracic Anaesthesiology (EACTA) has conducted a survey of opinion in order to create recommendations for the anesthetic approach to these challenging patients. It should be emphasized that both the management of the infected patient with COVID-19 and the self-protection of the anesthesia team constitute a complicated challenge. The text focuses therefore on both important topics.

12.
J Crit Care ; 58: 89-95, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32402931

RESUMO

PURPOSE: Perioperative myocardial dysfunction occurs frequently in cardiac surgery, and is a risk factor for morbidity and mortality. Levosimendan has been suggested to reduce mortality of patients with perioperative myocardial dysfunction. However, long-term outcome data on its efficacy in cardiac surgery are lacking. MATERIALS AND METHODS: Cardiac surgery patients with perioperative myocardial dysfunction were randomized to levosimendan or placebo, in addition to standard inotropic care. One-year mortality data were collected. RESULTS: We randomized 506 patients (248 to levosimendan 258 to placebo). At 1-year follow-up, 41 patients (16.5%) died in the levosimendan group, while 47 (18.3%) died in the placebo group (absolute risk difference -1.8; 95% CI -8.4 to 4.9; P = .60). Female sex, history of chronic obstructive pulmonary disease, previous myocardial infarction, serum creatinine, hematocrit, mean arterial pressure, and duration of cardiopulmonary bypass were independently associated with 1-year mortality. CONCLUSIONS: Levosimendan administration does not improve 1-year survival in cardiac surgery patients with perioperative myocardial dysfunction. One-year mortality in these patients is 17%. Six predictive factors for long-term mortality were identified. STUDY REGISTRATION NUMBER: NCT00994825 (ClinicalTrials.gov).

14.
J Cardiothorac Vasc Anesth ; 34(9): 2315-2327, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32414544

RESUMO

The novel coronavirus has caused a pandemic around the world. Management of patients with suspected or confirmed coronavirus infection who have to undergo thoracic surgery will be a challenge for the anesthesiologists. The thoracic subspecialty committee of European Association of Cardiothoracic Anaesthesiology (EACTA) has conducted a survey of opinion in order to create recommendations for the anesthetic approach to these challenging patients. It should be emphasized that both the management of the infected patient with COVID-19 and the self-protection of the anesthesia team constitute a complicated challenge. The text focuses therefore on both important topics.


Assuntos
Comitês Consultivos/normas , Manuseio das Vias Aéreas/normas , Anestesia em Procedimentos Cardíacos/normas , Betacoronavirus , Infecções por Coronavirus/cirurgia , Pneumonia Viral/cirurgia , Guias de Prática Clínica como Assunto/normas , Manuseio das Vias Aéreas/métodos , Anestesia em Procedimentos Cardíacos/métodos , Anestesiologia/métodos , Anestesiologia/normas , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/epidemiologia , Europa (Continente)/epidemiologia , Humanos , Pandemias , Pneumonia Viral/diagnóstico , Pneumonia Viral/epidemiologia
15.
16.
Curr Opin Crit Care ; 26(3): 313-318, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32348096

RESUMO

PURPOSE OF REVIEW: We will highlight the role of ventriculoarterial coupling in the pathophysiology of sepsis and how to assess it. RECENT FINDINGS: Most septic patients show a ventriculoarterial uncoupling at the time of diagnosis with arterial elastance (Ea) greater than left ventricle (LV) end-systolic elastance (Ees), often despite arterial hypotension. Ventriculoarterial coupling levels predict the cardiovascular response to resuscitation in this heterogeneously responding population. SUMMARY: Ventriculoarterial coupling is quantified as the ratio of Ea to Ees. The efficiency of the cardiovascular function is optimal when Ea/Ees is near one. When the hydraulic load of the arterial system is excessive either from increased vasomotor tone, decreased LV contractility or both, Ea/Ees becomes greater than 1 (i.e. ventriculoarterial decoupling), and cardiac efficiency decreases leading to heart failure, loss of volume responsiveness, and if sustained, increased mortality. Noninvasive echocardiographic techniques when linked with arterial pressure monitoring allow for the bedside estimates of both Ea and Ees. Studies using this approach have documented the key role ventriculoarterial coupling has defining initial cardiovascular state, response to therapy and outcome from critical illness. Sequential monitoring of ventriculoarterial coupling at the bedside offers a unique opportunity to assess relevant cardiovascular determinants in septic patients requiring resuscitation.

17.
Crit Care ; 24(1): 99, 2020 Mar 24.
Artigo em Inglês | MEDLINE | ID: mdl-32204718

RESUMO

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2020. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2020. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.

18.
Minerva Anestesiol ; 86(6): 645-651, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32013333

RESUMO

Appropriate weaning is of crucial importance for critically ill patients requiring respiratory support. However, a remarkable proportion of them are difficult to wean. Levosimendan is a positive inotropic agent characterized by vasodilatory properties, which is used for the treatment of acute decompensated heart failure or in patients needing inotropic treatment, including cardiogenic shock, septic shock, pulmonary hypertension and right ventricular dysfunction, needed for hemodynamic support in patients with diuretic resistance, and weaning either from ventilator or from extracorporeal membrane oxygenation. This position paper will discuss the use of levosimendan in facilitating weaning from cardiorespiratory support in critically ill patients, according to available evidence and the personal experience of a group of Italian Experts.

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